Although RTX can cause transient or permanent loss of lower limb function [4, 24] it is regarded to improve local control of high grade soft tissue sarcomas. This enables the surgeon to perform limb sparing surgery with the same results concerning local tumour control as with radical resection or amputation. Compared with a 50–70% relapse free survival of nonirradiated patients [4, 8, 19, 37] the success rate after RTX (70–100%) is much higher [3, 6, 7, 12–15, 17, 18, 28, 31, 38]. Whether to apply irradiation preoperatively or after tumour resection has been matter of debate in previous studies [7, 21, 24, 25].
Preoperative radiation may be indicated if tumour size is very big (>10 cm), if the localization is close to vital structures and radical resection otherwise is needed [11, 13, 21–23, 39, 40]. The histological response to preoperative radiotherapy has been more favorable in large and high grade tumours [13, 21, 36].
Preoperative radiation may still be useful for patients with tumours not amendable to a limb salvage procedure due to proximity of neurovascular structures [22, 40]. In these cases, brachytherapy can also be an alternative . Preoperative radiation has been reported to be beneficial in tumours after a shell out procedure resulting in an intralesional margin .
The theoretical advantages of preoperative irradiation include decreased intraoperative seeding of viable tumour cells in the operative field, sterilization of lymph node metastasis outside the operative field, a smaller tumour volume due to necrosis with formation of a pseudo capsule facilitating surgical resection [22, 23, 29, 36] and a reduced toxicity with smaller median radiation dose and field size  which is important since Yang et al. (1998) reported about transient lower limb strength and decreased range of motion in patients after postoperative radiation with 63 Gy on average. Also, preoperative irradiation seems to offer lesser late radiation morbidity by diminished fibrosis, joint stiffness and edema .
Disadvantages are an increased number of wound infections [7, 11, 13, 22, 25, 42, 43] with a possible detrimental effect on patient function  and other complications [2, 13, 44].
Concerning local control a positive outcome of preoperative administered irradiation is reported by Barkley et al. (1988) , Brant et al. (1990)  and Sadoski et al. (1993) . Suit et al.  compared preoperative versus postoperative radiation for soft tissue tumours and found no difference in overall survival but local control of large tumours was improved by preoperative irradiation. Suit and Spiro (1994)  reported a local success rate of 100% and 79% of 15 cm and 20 cm large tumours after preoperative radiation whereas a rate of only 50% and 67% was achieved with postoperative irradiation. Cheng et al. (1996)  compared preoperative with postoperative RTX in similar patient groups and did not find significant differences concerning local control and survival. More decisive for local control than the kind of irradiation is a correct tumour resection . A positive resection margin deteriorates local control significantly [28, 45]. Karakousis and Zografos (2002)  and Karakousis et al. (1986)  treated tumours with wide resection margins with surgery alone and tumours with a margin <2 cm with additional irradiation of 45–60 Gy. The 5-year local recurrence rate was 7–19% and 17–24%, respectively. This displays the potential of RTX to improve local control in problematic cases. The difference in local failure between wide and marginal resection with and without radiation concerning to Alho et al. (1989)  was 8% to 10 or 37%. Marginal resection alone has a convincing high risk and increased local failure rate . Our local control rate in the two observed groups was not statistically different (p = 0.38). The resection margins were equally distributed in both groups. Local relapse was treated by resection (six cases) or salvage amputation (two cases) and palliatively in two cases of multiple metastases.
Local control status has moderate influence on the development of metastasis [33, 45, 48, 49]. Metastatic disease is the most serious and limiting event in sarcomas [21, 23, 26, 29, 30, 32]. Suit et al (1988)  reported a 60% risk of metastatic disease in 15–20 cm large extremity soft tissue sarcomas. In our study group (n = 41) with comparable tumour size 56% of the patients developed distant metastasis although preoperative staging in all patients no later than 4 weeks prior to treatment was negative. The preoperative radiotherapy group was associated with 7/8 (87.5%) and the postoperative group with 16/33 (49.5%) cases of metastatic disease (p= 0.046, chi square). Occurrence of metastasis was not influenced by surgical margin (p = 0.68) or local control status (p = 0.24). The high percentage of metastatic disease caused a nonsignificant worse relapse free survival of the preoperative radiation group (p= 0.104). A similar outcome has earlier been reported by Cheng et al. (1996)  also as a tendency in a restricted group of their patients favouring the relapse free survival of the postoperative radiation group. Virkus et al. (2002)  reported 48% metastasis of their preoperative group and a local control rate of 86%. Wanebo et al. (1995)  reported 98.5% local control rate but 38% metastases after preoperative radiation despite simultaneous doxorubicin based chemotherapy. Current prospective trials use chemotherapy to improve distant disease-free survival resulting in a significant improvement of 75% versus 44% compared to a historical control group . The combination of chemotherapy with regional hyperthermia has shown promising results .
In a prospective randomised study of preoperative versus postoperative RTX by O'Sullivan et al. (2002)  regional and distal failure rates were identical but in this study low grade (17%) and superficial (16–21%) tumours were included. Nevertheless, this strong study suggests that the results of our retrospective study are not universal valid. An acknowledged deficiency of our study might be the preselection bias inherent in all review studies making validity and reliability of the results questionable. Although we did not intend to preselect patients for any of the two examined groups our patients are not equally proported (33-8) and smaller than other reported series. Despite, they are restricted to a well-defined cohort of patients treated in a uniform manner and relatively well balanced (see Table 1, 2). Average age, stage, tumour size, depth, anatomic localisation and the resection margin were equal in both groups. In addition, our study group quite apparently displays an antiquated therapy regime for in this group despite a high risk tumour no chemotherapy was used. Chemotherapy today is a widely accepted and important part of all randomised evidence-based treatment protocols. We decided to enrol only patients who did not receive chemotherapy to exclude any possible influence of this treatment on survival and the incidence of metastasis in order to have a unique statement about the possible influence of radiotherapy.
An average loss of time from initialization of preoperative irradiation to tumour resection of 5 weeks and additional 3 weeks to allow the soft tissue to recover  can be expected. The loss of time to surgical resection with viable tumour in situ when irradiation is not fully effective might deteriorate distant disease control. Willett et al. (1987)  could find >80% necrosis in 69% of his patients with large tumours >10 cm after preoperative radiation. Robinson et al. (1992)  showed in 60% of their preoperative radiated patients a response with tumour reduction but without clinical correlation. Other experimental and radiographic studies report that a reduction in tumour volume may only be achieved in 40–60% with even tumour progression in 12–15% . Pitson et al. (2004)  stated that preoperative radiation reduced tumour volume (-59%) in liposarcoma but was ineffective in diminishing tumour size in other entities (MFH, +7% volume). Hew et al. (1994)  demonstrated only 26% of other than liposarcoma tumours with >80% necrosis. Our study group had mainly <50% tumour necrosis after preoperative RTX unrelated to further clinical outcome. The value of tumour necrosis estimation for radiosensivity and the clinical course of different entities remains arguable . Another problem is that negative staging does not rule out occult micro metastasis. This might bias our findings concerning metastasis after radiotherapy. At least, this problem affects both study groups.